REHOUSING HOMELESS CITIZENS WITH ASSERTIVE COMMUNITY TREATMENT. EXPERIENCES FROM AN ACT-PROGRAMME IN COPENHAGEN

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1 Lars Benjaminsen 07:2013 WORKING PAPER REHOUSING HOMELESS CITIZENS WITH ASSERTIVE COMMUNITY TREATMENT. EXPERIENCES FROM AN ACT-PROGRAMME IN COPENHAGEN SFI THE DANISH NATIONAL CENTRE FOR SOCIAL RESEARCH

2 REHOUSING HOMELESS CITIZENS WITH ASSERTIVE COMMUNITY TREATMENT. EXPERIENCES FROM AN ACT- PROGRAMME IN COPENHAGEN Lars Benjaminsen THE DANISH NATIONAL CENTRE FOR SOCIAL RESEARCH, COPENHAGEN, DENMARK; Working Paper 07:2013 The Working Paper Series of The Danish National Centre for Social Research contain interim results of research and preparatory studies. The Working Paper Series provide a basis for professional discussion as part of the research process. Readers should note that results and interpretations in the final report or article may differ from the present Working Paper. All rights reserved. Short sections of text, not to exceed two paragraphs, may be quoted without explicit permission provided that full credit, including -notice, is given to the source.

3 Rehousing Homeless Citizens with Assertive Community Treatment Experiences from an ACT-programme in Copenhagen Lars Benjaminsen June 2013 SFI The Danish National Centre of Social Research Herluf Trolles Gade 11, DK-1052 Copenhagen K, Denmark. Contact details: Lars Benjaminsen,

4 Content Summary Introduction Assertive Community Treatment an evidence based method Method of the study The ACT-programme and the national homelessness strategy The context of the Danish welfare system The citizens The housing The support provided Housing outcomes Independent housing versus communal housing Other outcomes Conclusion References

5 Summary This report presents the results of a study of an ACT-programme (Assertive Community Treatment) in Copenhagen, Denmark, which has been part of the Danish national homelessness strategy. The ACT-programme is aimed at rehousing homeless individuals and providing floating support in the citizens own home from a multidisciplinary support team. The target groups of ACT are homeless individuals with complex support needs due to for instance mental illness and/or substance abuse and for whom it is difficult to use mainstream support systems. The team consists of both social support workers and other professionals including a psychiatrist, a nurse, an addiction councilor, and social workers with administrative authority from the social office and the job center. In the international research literature ACT has been shown in randomized controlled trials to be a very effective method in bringing individuals out of homelessness and into a stable housing situation. The study is based on quantitative outcome measurement on about 80 citizens who have been assigned to the programme and who have received both a housing solution and support from the ACT-team. The study is not a randomized controlled trial as there is no control group. Furthermore qualitative interviews have been carried out with fifteen citizens receiving the support and eight staff members of the team. The study shows that a very high part more than 90 pct. of the citizens who have been assigned to housing and support remains housed throughout the observation period. About two fifths of the citizens have been housed in independent apartments in ordinary public housing and the rest have been housed in four different congregate housing units places where all residents are formerly homeless or otherwise socially vulnerable individuals. In both housing types more than 90 pct. remain housed throughout the observation period. However, a considerable part of the citizens in congregate housing has been relocated to other forms of housing mainly to independent public housing during the observation period. It has not been possible to control for initial selection of participants to the different forms of housing. The qualitative interviews show that the possibility to meet different dimensions of support needs - social support needs, health needs and administrative support needs is crucial to the success of the ACT-method. The incorporation of both specialist health professions and staff with administrative authority into the team gives a high degree of flexibility of giving tailor-made and coherent support to the citizens. 3

6 The individuals who have been housed in independent, scattered housing are very satisfied with both their housing situation and the support from the team. Amongst the individuals in the congregate housing units there are mixed experiences most are satisfied with their apartments but there are also indications that gathering many people with complex problems at the same place creates negative synergy effects especially by maintaining an environment characterized by substance abuse. The relocation of citizens from congregate housing units to independent housing during the programme period follows both the wishes of the citizens and the negative experiences of congregating many individuals with the similar problems in the same housing units. The study shows that ACT is a very effective method of supporting homeless individuals with complex needs to move into own housing and to remain housed. Especially, the study shows that with the support from an ACT-team it is possible to live in independent, scattered apartments in ordinary housing even for individuals with complex support needs. The experiences from the project point towards housing in independent, scattered housing as the preferable and optimal form of housing, though no conclusive evidence can be given on the relative effectiveness on the different housing forms, due to possible selection of citizens to the different housing types. The results also suggest that congregate housing should be reserved for individuals who are not able to live in ordinary housing even with the intensive support of an ACT-team and only after housing in independent housing has been tried, as it is not possible in advance to predict who will succeed. 4

7 1. Introduction In 2010 an Assertive Community Treatment (ACT) team was established by the municipality of Copenhagen as part of the Danish national homelessness strategy. The multidisciplinary team provides floating support to a group of formerly homeless individuals who at the same time are assigned to permanent housing through either the municipal priority allocation system or in congregate housing facilities attached to the programme. This report presents and discusses experiences from the ACT-programme based on quantitative data for all citizens attached to the programme, and qualitative interviews with eight staff members and fifteen citizens. The study is part of the study Housing First Europe, which has been financed by the European Commission by the PROGRESS programme. The empirical data will also be used for the evaluation of the national homelessness strategy. Section two gives an overview of the ACT-method. Section three describes the methodology of the study. Section four gives an overview of the context of the national homelessness strategy, and section five contextualizes the programme within the Danish welfare system. Section six describes the citizens enrolled in the programme. Section seven describes the housing used in the programme, and section eight describes the support involved. Section nine describes the housing outcomes, and section ten describes the experiences with independent housing versus congregate housing. Section eleven describes outcomes on other parameters and section twelve gives concluding remarks. 5

8 2. Assertive Community Treatment an evidence based method The ACT-method originated in the field of psychiatry. Following the de-institutionalization of psychiatric treatment in the 1960 and 1970 outpatient care was established on a local level typically in community mental health centers. However, the community based care often turned out to be less effective than anticipated and the ACT-method was developed as a more intensive method of providing support to individuals with complex support needs (Thompson et al., 1990) During the 1990s the ACT-method increasingly found its way into homelessness services as a way to provide floating support for homeless individuals being rehoused. ACT is aimed at individuals with complex support needs for whom it is difficult to use existing services such as treatment for mental illness, addiction treatment and other social services. ACT is based on a multidisciplinary support team providing floating support in the individuals own home. In particular the ACT-method has become associated with the turn away from treatment first /continuum-of-care programmes towards the housing-first approach. The key idea of the housing first approach is to establish a permanent housing solution as early as possible in the course of an intervention, and to provide sufficient floating support which enables the individual to stay housed. The pioneer of this approach was the Pathways-to-Housing programme in New York City led by Dr. Sam Tsemberis. In a manual for Housing First, Tsemberis (2010) describes how the Pathways programme is based on the combination of two elements independent scattered housing and floating support in the form of either ACT assertive community treatment or ICM intensive case management depending on the degree of support needs. By independent scattered housing is meant independent flats in ordinary residential areas. In the Pathways programme housing is obtained in private rented housing as public housing options in the US are scarce and waiting lists long. However, independent housing might as well be provided through public housing. An important aspect of the Housing first approach is that no conditions of adherence to treatment or behavioral progress such as abstinence is set as a condition for obtaining housing. The individuals have the same lease conditions as any other residents regarding for instance noise and no drug dealing. However, a condition is that the individual must accept to receive support from the team in the form of a home visit at least once a week. An ACT-team is a multidisciplinary team of professional specialists such as social workers, a psychiatrist, an addiction councilor, a housing specialist and a job consultant. Also peer specialists individuals with own former experience of homelessness may be included in the team. Support is given directly to the individual in his or her own home. However, for individuals with less complex 6

9 support needs, and who are capable of using mainstream services, support from an individual case manager (ICM) may be sufficient. The individual case manager provides both practical support at home and supports the individual in using mainstream support services such as psychiatric services and addiction treatment. An important aspect of housing first is the separation of the housing solution and the social support, in the sense that access to housing should not be conditioned upon following treatment. Except for the initial agreement to accept regular visits from the support team, obtaining a housing contract and the conditions of eviction should not be conditioned upon a requirement to follow addiction treatment or of abstinence. In case of an eviction the social support follows the individual and the ACT-support should not be interrupted due to a loss of housing. The housing intervention in the Pathways programme is based on independent, scattered housing in the ordinary housing sector, instead of congregate/communal housing units where all residents have complex support needs (in Scandinavia known as category housing housing for individuals of the same category ). In the literature communal housing has been criticized for the risk of negative synergy effects (see e.g. Blid 2008). By bringing together many individuals with strong support needs, mental illness and/or addiction problems, there is a risk of maintaining the individual in an environment marked by addiction, social problems, and conflicts amongst the residents. Contrary to congregate/communal housing, scattered housing in the community may involve positive community effects from the interactions in everyday life with other residents in the community. On the other hand the independent scattered housing model may pose a risk of loneliness as many individuals with complex support needs have weak or no social relations. The effectiveness of ACT as a method to stabilize the housing situation of formerly homeless individuals has been tested in randomized effect studies. A study by Tsemberis et al. (2004) where ACT in combination with independent scattered housing was tested against usual care and with a follow-up period of 24 months shows that amongst the intervention group receiving ACT in combination with independent scattered housing about per cent are in a stable housing situation whereas in the control group only about 30 per cent were in a stable housing situation at the two-year follow up. Other studies have pointed to the effectiveness of the ACT-method as well. In a meta-analysis of six randomized studies of ACT-support Coldwell and Bendner (2007) find an average effect difference on homelessness outcome measures of 37 per cent in favor of ACT compared to a control condition of standard care. In most of the studies the control group received some form of ordinary 7

10 case management. In the same meta-analysis a 26 per cent greater improvement was found in psychiatric symptom severity for the ACT-intervention group compared with standard care. However, no significant difference was found between the two groups in hospitalization outcomes. A further review (Nelson et al. 2007) suggests that the effect of both ACT and ICM is enhanced when combined with a housing programme. However, still relatively few effect studies have been made, and certain questions can be raised. Kertesz et. al. (2009) has argued (p. 522) that the housing first programmes reported in the literature mainly includes individuals with a non-addiction psychiatric disorder, whereas the severity of substance abuse has been moderate. This raises the question whether the residual group who do not succeed in maintaining housing in these studies is likely to include a higher number of individuals with severe and active substance abuse, and whether other housing solutions such as communal housing may be needed for this group? Furthermore it should be noticed that almost all effect studies so far has been conducted in the US. This might especially affect the control condition, as the content of usual care might vary according to the welfare regime. In this study of the Danish ACT-team there is no control group but only an intervention group receiving ACT-support and housing. However, the study gives an estimation of how many amongst the participants who maintain a stable housing situation during the follow-up period. At the same time the Danish ACT-programme involves different types of housing. Some participants have been assigned to independent scattered housing and others have been assigned to communal housing. This gives an opportunity to compare outcomes and experiences between the different types of housing, though there may be an element of selection to the different housing types through the assignment process. 8

11 3. Method of the study The study of the ACT-programme in Copenhagen is based on both quantitative and qualitative data. Since the beginning of the ACT-project, a quantitative monitoring system measuring outcome for each individual receiving support has been in place. This monitoring system is part of an evaluation of all projects financed under the national homelessness strategy. Data from the monitoring system is used in the study. 1 Every third month data on each participant is entered into the system by case workers. Besides basic demographics of the citizens receiving support, information is given about housing status, extent of the support received and which type of professions in the team whom the individual have received support from. There is also information on a range of other measures such as an assessment of the extent of addiction problems, mental problems, ability to maintain daily activities, social network etc. The quantitative measurement is based on the assessment by support workers and not on self-reporting of the citizens. In addition to the quantitative data from the monitoring system of the national homelessness strategy, specific information on housing status and reasons for changes in housing status for all citizens has been collected from the ACT-team specifically for this study. Besides the quantitative data, qualitative interviews have been conducted with team staff and with citizens who receive support from the team. Most qualitative interviews were carried out during May and June 2012 and some were carried out in a second round of interviewing in January and February At the time of interviewing the team had 14 staff members including the team leader. Some staff members work only part time in the team. Qualitative interviews were carried out with the team leader and seven staff members. A second interview was conducted with the team leader in January In the selection of staff members for interviews the priority has been to cover the variety of professional disciplines represented in the team. The interviewed staff members are a psychiatrist, an addiction councilor, a nurse, a job consultant, a social welfare officer, and two social support workers. One of the interviewed support workers is an on-site support worker in one of the group homes and this support worker is not formally part of the ACT-team. This arrangement of attaching the ACT-team to communal housing/group homes with on-site support staff will be explained in a further section. Thematized interviewguides were made for each interview with a 1 The monitoring system for the Danish Homelessness Strategy has been set up and is administered by Rambøll and quantitative data from the monitoring system has been provided for this study through Rambøll Results. 9

12 special focus on the treatment and support given by each particular professional. Each interview lasted about 1-1½ hour. Fifteen qualitative interviews were carried out with citizens receiving support from the team. Contact to the interviewees was facilitated by staff members of the team who undertook a great effort to engage citizens for interview. Most citizens who receive support from the team were approached about whether they would participate in an interview. A few citizens were not approached due to the severity of their condition. Initially the ambition was to carry out interviews with 20 citizens, but it turned out not to be possible to engage this number of citizens for interviews. The staff members who have facilitated the contact point to the fact that most of the citizens receiving support from the team obviously have very complex support needs, and most have severe addiction problems, which is of course a barrier for committing to an interview. There is a risk that it is the more resourceful among the citizens who have committed to an interview. However, it should be recognized that complex support needs is a general condition for being assigned to support from the team and that all the interviewees can be characterized as having complex support needs. The interviewed citizens were eleven men and four women, four were in years old, five were years old and six were years old. Six lived in independent housing, two lived in a group home, four lived in a large communal housing unit and three lived in another communal housing unit consisting of row houses. Fourteen of the interviewees were Danes, of whom three had Greenlandic background. One had a different nationality than Danish. Thematized open-end interview guides were used. Priority was given to the interviewees view of their housing situation, and the support they receive from the team and whether this support covers their needs. A decision was taken by the researcher not to emphasize questions about the interviewees life history, homelessness trajectory and personal problems such as addiction history and mental illness unless these subjects came up naturally during the interviews as these themes might strain the interviewees unnecessarily. The focus on the housing situation and the support received from the team, was also communicated to potential interviewees in the process of engaging citizens for interviews. However, in most cases it turned out to be a natural part of the conversation to ask where the interviewees stayed before they moved into their current home, and in most cases also the issue of addiction problems came up. It was the general impression from the interviews that all interviewees were keen on expressing viewpoints on both their housing situation and the support they received. All interviews were carried out in the homes of the citizens. The names of both staff 10

13 and citizens have been changed in the report. Also the names of the communal housing units have been anonymized to communal housing unit I, communal housing unit II (row houses), group home I and group home II. 11

14 4. The ACT-programme and the national homelessness strategy In 2008 the Danish government adopted a national homelessness strategy. Four overall goals were set: That rough sleeping should be reduced, that young homelessness individuals should have alternatives to a stay in a homeless shelter, that the length of stays in a shelter should be reduced for individuals capable to move on, and that homelessness following institutional release from prison or hospitals should be reduced. A pool of 500 million DKK (66 million ) were allocated to the strategy over a four year period. Eight municipalities, primarily the largest cities and town, with the highest level of homelessness were invited to participate in the strategy. At a later stage additionally nine mainly medium sized municipalities received funding from the strategy, particularly aimed at strengthening floating support services. The eight municipalities were asked to set local goals and to initiate specific interventions to fulfill these goals. The initiatives were to be agreed upon between the municipalities and the Social Ministry. Priority was given to developing social methods effective in bringing individuals out of homelessness. Existing knowledge on such methods was consulted. In particular priority was given to set up projects based on three support methods which had already shown to be effective in the international research literature Assertive Community Treatment, Intensive Case Management, and Critical Time intervention. Another priority was given to provide new housing for the homeless and part of the funding was allocated to projects providing new housing units for the homeless. The first national count of homelessness in week 6, 2007 had shown that the highest number of homeless was found in the municipality of Copenhagen with 1,884 homeless individuals registered in the count week, out of a national total of 5,253 homeless individuals, thus corresponding to 36 per cent of the national total (Benjaminsen & Christensen, 2007). The definition of homelessness used in the count was based on an adapted version of the European Typology of Homelessness and Housing Exclusion (ETHOS), and had as main categories rough sleepers, individuals in emergency night shelters, homeless shelters, and individuals staying temporarily with family or friends (couch surfers). The municipality of Copenhagen received 200 million DKK (27 million ) to set up new initiatives and a variety of new initiatives was agreed upon. One initiative was to establish an ACTteam to provide support to homeless individuals with complex support needs who should be assigned to housing as part of the programme. The ACT-team became anchored under the existing homelessness unit in the Social Department of the municipal administration. 12

15 As mentioned earlier the distinctive feature of the ACT-method compared to other forms of floating support such as ordinary case management, is that multiple professional disciplines are integrated into the team, and all provide outgoing floating support in the home environment of the citizen. Not all of the professional disciplines were part of the team from the beginning, as some were attached to the team after a while. At the time of interviewing in summer 2012, the team consisted of a team leader, 7 full time social support workers, a full time nurse, a part time psychiatrist who also specializes in addition problems and works two days a week for the team, two part-time addiction councilors (each working one day a week for the team), one full time and one half time social office case worker, and one part-time job center case worker. According to the team leader the average yearly cost per citizen is about 88,000 DKK (about 11,500 ). This excludes housing costs. The citizens pay rent for their housing out of their transfer income (mostly cash benefit or early retirement benefit). 13

16 5. The context of the Danish welfare system The assignment of a citizen to receive support from the ACT-team means that he or she can receive the specialized professional support from the team at home. Besides the possibility to get floating social support from the social support workers this also means that the citizen does not need to attend meetings at the job center concerning social benefits as this can be taken care of directly by the job office worker in the team, or to go a addiction treatment center for substance addiction treatment, as such treatment can be given directly from the addiction councilor in the team. However, the assignment to the ACT-team does not as such exclude the citizen from receiving support from other welfare services. Especially in the field of health care (both somatic and psychiatric) Denmark has universal coverage which means that the ACT-citizens have the same rights as all other citizens to receive public health care. However, by incorporating a nurse and a psychiatrist (who also has general medical competence) into the team additional treatment can be given directly in the citizens own home. The nurse can also assist the citizen in contact with the general health system and thus facilitate the citizen s use of the general health system when necessary. The possibility to receive addiction treatment directly from the addiction councilor in the team does not as such exclude the possibility of receiving treatment in the general addiction treatment as assignment is considered in each individual case. While some of the ACT-citizens receive medical substitution treatment for opioid addiction, only a few receive psychosocial addiction treatment in the regular treatment system, whereas most who receive psychosocial addiction treatment do so from the addiction councilor in the team. All of the citizens attached to the team receive some form of transfer benefit. Of those attached to the team in January 2013 the majority (69 out of 77) received cash benefit. 7 received disability pension and one received old age pension. The level of cash benefits is approximately the equivalent of 1100 pr. month after tax, the early retirement pension is about 1,600 after tax and the old age pension is about 1200 after tax. Both in independent housing and communal housing the rent must be paid out of transfer benefits. In addition there is a housing benefit (calculated on the basis of rent and income) which gives a supplement to cover part of the housing cost. Cash benefit receivers can be required to follow labour market activation programs or other kinds of social activity programs but individuals can be exempted due to social problems. Most of 14

17 the cash benefit receivers amongst the ACT-citizens are not required to follow activation programmes due to the severity of their support needs, but depending on individual capabilities it is possible to follow such activity programs. 15

18 6. The citizens In January 2013 a total of 92 individuals had been assigned to the programme. 80 had been assigned to housing through the project so far, while 12 were waiting to be assigned to housing, most of whom had been assigned to the team very recently. At the time of the last interview in January 2013 the ACT-project was closed for new participants as the number of citizens receiving support had reached maximum capacity. New participants are only accepted when somebody leaves the programme. There were a total of 76 citizens actively receiving support from the team. The remaining citizens did no longer receive ACT-support for various reasons. Five citizens died throughout the programme period, at the average age of only 41 years, reflecting a high mortality amongst long-time substance abusers. The assignment to the ACT-team is made by an assignment team in the municipality s homelessness unit. The assignment team has the possibility to assign individuals to different forms of housing and support where the ACT-team is one amongst several options. The ACT-team is aimed at individuals with complex support needs, for whom support from a regular social support worker is assessed not to be sufficient. The team leader explains that there are individuals who have so severe support needs that these needs cannot be met by ACT-support and whom it is therefore not possible to assign to the programme. These are for instance individuals with intensive care needs, such as a need for intensive daily support, and who are the target group for so-called 108 accommodation which is institutional accommodation with full-time on-site support. There are also some substance abusers who have been assessed not to be possible to house and support through the ACT-programme, due to a very chaotic behavior. The citizens who are assessed to be within the target group of the ACT-team are asked about their housing preferences and particularly whether they wish to live in independent accommodation or if they want to live together with other formerly homeless individuals in which case referral to one of the communal housing units is possible. The assignment team widely follows the citizens own housing preferences but the assignment team may consider that some individuals cannot be offered a certain type of housing due to behavioral issues. Amongst the interviewed citizens there are two who were initially offered a place in the communal housing units but declined this offer, and both these individuals were instead offered to move into independent housing. In table 1, demographics are shown for 87 citizens who have been assigned to the project in total, excluding five citizens who have died during the programme period. 16

19 Table 1: Gender of the ACT-citizens Per cent (count) Female 32 (28) Male 68 (59) Total 100 (87) Table 2: Age of the ACT-citizens Per cent (count) (0) (7) (19) (32) (27) (2) Total 100 (87) Table 3: Ethnic background of the ACT-citizens Per cent (count) Danish 59 (51) Danish from Greenland 30 (26) Other nationality 12 (10) Total 100 (87) About two thirds of the ACT-citizens are males, and only one third females. A few are younger than 30 years old, but most are from 30 years and upwards, with year olds being the largest group. 89 per cent (77 individuals) are Danish including 26 individuals with Greenlandic background. 12 pct. (10 individuals) have another nationality than Danish. 17

20 7. The housing At the onset of the ACT-programme a decision was taken by the municipality mainly to assign citizens in the ACT-programme to communal housing units. There was a perception among municipal decision makers and administration that many of the individuals with complex support needs would not be able to live on their own in independent housing, and that specialized housing would be needed for this group. There was also a concern of providing enough housing units for the project, as there is a general shortage of affordable, independent public housing for allocation under the municipal priority access scheme (explained below). A decision was taken, to provide housing in three separate communal housing units in the city. A further fourth unit has later come into use. However, some individuals were also housed in ordinary public housing, and as the experiences with housing some of the ACT-citizens in ordinary public housing were very positive it was decided to assign more of the ACT-citizens to ordinary housing. At the same time experience from the communal housing units began to show signs of negative effects from congregating many individuals with similar problems at the same place, and a number of residents at the communal housing units have during the observation period moved from communal housing and into independent housing in ordinary public housing. Independent housing The municipality of Copenhagen can assign one third of all housing units which become vacant in public housing in the municipality to households in priority need of housing. Many groups compete for such assignment such as single mothers, individuals with physical handicaps, mentally ill individuals with a housing need, and homeless individuals with social problems. Demand generally exceeds supply and there is a waiting time to get an apartment through this priority access scheme. The team leader assess that average waiting time is about 4-6 months for assignment to independent housing. However, for individuals with a dog, the waiting time is about one year, as a number of housing organizations do not allow pets. For individuals under 25 years the waiting time is generally longer, as cash benefits are lower for individuals under 25 years, and therefore fewer of vacant apartments are affordable for this group. The apartments which have been allocated to ACT-residents are generally scattered all over the city. All individuals who are allocated to public housing get a permanent ordinary rental contract. The residents pay rent out of their cash benefit or early retirement allowance. 18

21 Communal housing I One of the communal housing units that have been attached to the project as ACT-housing is a large 10-storey housing block with a total of 70 apartments. The house is owned by a public housing company and all residents have their own rental contract. The municipality provides support for the residents, and previously the place was a residential unit only for individuals with mental illness. As demand for this particular form of housing for the mentally ill declined, the municipality decided that 20 of the apartments should instead be converted into housing for the homeless, and be attached to the ACT-programme. At the same time the administrative responsibility for the support was moved from the municipality s health department to the social department. The 20 apartments should over-go to the ACT-programme as they become vacant. Each apartment consist of one room with own kitchen and a bathroom and with separate entrance from a regular stairway. In the ground floor there are common rooms and on-site staff facilities. Until April 2012 a model of divided support between on-site staff and the ACT-team was used in this housing unit. It was the same staff that used to service the mentally ill residents in the rest of the complex who should also deliver on-site social support to the formerly homeless residents. The ACT-staff should then provide additional support from the professions represented in the team. However, the on-site staff did not have any particular experience with homeless individuals with complex support needs. From April 2012 the ACT-team took over the full support for the residents housed through the ACT-programme. At the summer apartments had become available for the ACT-programme. As will be discussed later, conflicts have occurred in this communal housing unit about access to the common facilities for the formerly homeless residents, and at the time of the first interviews in summer 2012 it had been decided by staff in the house that the ACT-citizens cannot use the common facilities in the ground floor. Furthermore there was a general experience of negative effects of congregating many individuals with addiction problems in this facility. During autumn 2012 the municipality has decided to offer the ACT-citizens in this communal housing unit relocation into other housing and mainly into independent public housing if the citizen wants such relocation. Group home I In the case of one of the communal housing units, it was decided by the municipality that support from the ACT-team should be assigned to a group of residents already living at this place. The unit is a group home with 20 rooms dispersed in six separate apartments in the same stairway in an 19

22 ordinary apartment building in the inner city. In each flat the residents share bath and kitchen. 14 of the rooms are reserved for individuals with Greenlandic minority background. In the group home there is tolerance of use of alcohol and hashish. Users of hard drugs are generally not assigned to the place but eventual use of hard drugs is not sanctioned with eviction as the residents have their own rental contract. Only 15 of the rooms were occupied at the time of the first interview round in summer According to the staff interviews one reason why there are empty rooms at the place is that many potential residents do not want to live at the place and many would rather prefer to live in an independent flat. Another reason is that individuals with use of hard drugs are not assigned to the place. A reason why it was decided that the group home should be included in the ACT-project was that a strengthening of the support given at the place was needed. Before the ACT-team was attached only one social worker and a part-time nurse were attached to the place. However, it was decided that two on-site support workers with a base in a homelessness shelter should be attached to the place and provide daily social support to the residents whereas the ACT-team should provide additional support by the professions in the team. In this way the ACT-team does not provide full floating support to the residents, as the on-site social support workers are not as such part of the ACT-team. Nine residents lived at the place at the time the ACT-team and the support workers were attached to the place. According to the staff interviews, the residents already living at the place all became attached to ACT-support without any extensive assignment procedure. A staff member assesses that almost all of the residents belong to the target group for ACT by having complex support needs, but that a few might not fall under this category. However, all residents were attached to ACT-support as nobody should need to change their place of residence. Group home II Another communal housing unit which has been attached to the ACT-project is a small group home where there is room for 10 residents. Two of the housing units are flats with own kitchen and bath whereas 8 rooms share facilities. Only 7 rooms were occupied in May As was the case for the first group home, there is a lack of demand to live in the place. Also in this place, daily social support is given by on-site support workers, not part of the ACT-team, whereas the team provides additional support. Like in the second communal housing unit described above, the interviews point 20

23 to certain challenges in this facility. The existing staff of the place did not have previous experience with the ACT target group. During 2012 a decision has been taken by the team and the municipality to end the attachment of this place to the ACT-programme and to offer the ACT-citizens in this place to move to other accommodation. At the time of the second interview round all ACT-citizens but one, in this facility, has accepted this offer. Communal housing II During summer 2012 a new unit of communal housing was attached to the ACT-programme. The new housing unit consists of 18 small rowhouses 1 or 1½ room each with own kitchen and bath. The place used to house mentally handicapped individuals. All interior of the houses has been rebuilt. Based on the experiences from the existing group homes there is no on-site staff and all support will be supplied from the ACT-team. 21

24 8. The support provided The ACT-team consists of staff with different professional backgrounds. Besides social support workers (most of whom have a social pedagogical degree) the team includes a nurse, a psychiatrist, an addiction councilor and a social office worker and a job center worker, both with discretional authority over support and benefits. All support is given as floating support in the citizens own home. The monitoring system provides information on the extent of support given to the citizens. Table 4 shows how often support is given for citizens receiving support. Only data from the last measurement period in November 2012 is included. Only citizens attached to the team at the time of measurement (for each period) are included. A few citizens have not allowed for data to be collected. 18 per cent of the ACT-citizens receive daily support. This mainly reflects the availability of on-site support in one of the group homes. The majority of the citizens receive support from about two times a week to about every second week. 13 per cent (7 persons) have received support only once a month or less in November This probably reflects cases where it is difficult for the team to deliver support to the citizen for instance if the citizen resists support visits or it is difficult to make an appointment if the citizen is not at home or responding to phone calls. Table 4: How often has support been provided (citizens receiving support in November 2012, on average within last three months) Frequency of support Per cent (count) Daily 18 (10) About two times a week 13 (7) About once a week 36 (20) Every second week 20 (11) About once a month or less 13 (7) Total 100 (55) Also the duration of support visits is recorded in the monitoring system. Briefer and more frequent contacts in the group homes probably explain why some visits are relatively short. However, two thirds of support visits last longer than 45 minutes and one out of four visits even last more than 1½ 22

25 hours. This underlines how the individual support provided from the ACT-team is relatively intensive. Table 5: Duration of a support visit (citizens receiving support in November 2012) Frequency of support Per cent (count) 1-5 minutes 0 (0) 6-15 minutes 4 (2) minutes 22 (12) minutes 15 (8) minutes 27 (15) minutes 13 (7) More than 90 minutes 20 (11) Total 100 (55) The monitoring system also provides information on which of the professions represented in the team has been in contact with the citizens. 84 per cent of the ACT-citizens receiving support in November 2012 have had contact with a social support worker within the last 3 months. The team leader explains that the reason why not all citizens have been in contact with a social support worker at that time is changes in the staff group as a social support worker had a new job and until replacement was found other team staff for instance the nurse had the primary contact to the citizens who were attached to this support worker. 64 per cent has been in contact with the nurse, reflecting that many of the ACT-citizens also have health problems, and furthermore that the nurse generally aims at meeting with all ACT-citizens at some point in time after their assignment to the team. Almost one out of three has been in contact with the psychiatrist. 18 per cent has been in contact with the addiction councilor. 69 per cent has been in contact with the social office worker. A third of the citizens have been in contact with other staff which may be the case worker from the job center who has authority over cash benefits, and assignment to activation projects. The results clearly illustrate how the support which the citizens receive is multidisciplinary. This is where the ACT-method differs from brokered case management, where the case manager facilitates access to mainstream support services. 23

26 Table 6: Which type of staff has had contact with the citizen during the last 3 months (citizens receiving support in November 2012). Staff category Per cent (count) Social support worker 84 (46) Social office worker 69 (38) Social assistant 4 (2) Nurse 64 (35) Psychiatrist 29 (16) Addiction councilor 18 (10) Other 22 (12) Total 100 (55) 8.1 Three dimensions of support There are three main dimensions in the support provided from the ACT-team. First, there is the social and practical support delivered mainly by the social support workers. Second, there is health related support physical and mental provided by the nurse, the psychiatrist and the addiction councilor. Third, there is administrative support where the inclusion of the social office case worker and job center case worker as members of the team means that decisions regarding cash benefits and other kinds of social services can be dealt with in a flexible manner. Social support The social support covers many aspects of daily life having somebody to talk to about challenges in everyday life, social relations etc. There is also a considerable element of practical support such as helping to keep order in the apartment, helping with doing the dishes now and then, and support to paying bills, and assistance to access other kinds of services not covered by team, such as going to the hospital, to the doctor or to the dentist. Especially there is an intensive period of support when moving in, where the support worker both helps with practical things such as getting furnished, and the social and emotional adjustment to the new life in the apartment. 24

27 In the interviews the citizens generally describe their relation to their social support very positively. Several of the interviewees emphasize the crucial importance of the support they receive from the team. Some explicitly states that without this support they would not be able to live on their own. Asked about what he thinks about the support he receives, an interviewee says: Interviewee: It has been good. She [his support worker] comes once a week, and we start by opening my mail, and take care of my bills, and she follows me to the tax office to fix it. I am in activation [a job activation programme], but I have not been there for a month, because a friend of mine is living here, and he goes on my nerves. Nothing will happen with your money, don t worry, we will make sure there will be no sanctions She is.i call her, and then she calls me up in the morning and makes sure I will go to the activation Interviewer: And do you feel you can get in touch with her when you need to? Interviewee: Yes I can, I call her, and if she is off, she calls me back in the morning. Interviewer: What if you imagine that you did not have Else [support worker] to help you with your bills and..? Interviewee: Then I would not have had this [apartment]. Interviewer: Then you would have lost it again? Interviewee: Yes I would, then I would not have had this. Interviewer: So you feel that it is what makes you being able to live here? Interviewee: Yes, I get a lot of help, when I need it. Another interviewee says that previously he had often felt let down by the social system, but has had a very different experience with the ACT-team. He explains about his initial contact with the social system when he was assigned to the project that he was offered help by the system, and that he felt he was recognized as being somebody, and that he was asked what can we do for you. The interviewee is a non-native Danish speaker, his wording is: Before I got my apartment my motivation was high. I often had an overdose. Then the system comes and says we can help you, so I am happy. I had many times an overdose, in hospital, it was enough. The contact with the system, the authorities, the confirmation that you are here, what can we do for you. 25

28 Asked what he thinks about the support he gets from the team he says: It gives confidence. If I don t feel well, then Jane [the nurse] comes hi and Jens [social support worker] how are you. It gives ah not acknowledgement [he is looking for the wording] but that I exist. Health support The team includes a full time nurse, a part-time psychiatrist (two days a week), and two part-time addiction councilors each working one day a week for the team. The psychiatrist also specializes in addiction problems, and consults on physical/medical problems of the citizens. The nurse describes how she sees all citizens shortly after their enrollment, to assess their need for health related support. She estimates that at the time of the interview she regularly sees about of the citizens. Most of them she sees every second or third week, but at times there are citizens she visits almost on a daily basis, especially if they have acute sores. The psychiatrist assesses that he has been in contact with about half the citizens attached to the team, and that at a given time he is in contact with about 15 citizens. The addiction councilor estimates that she currently has contact with 10 citizens, and so we may assume that the two addiction councilors altogether are in contact with about 20 citizens. However, as mentioned the number of citizens with contact with the addiction councilor has fallen toward the end of the observation period. There are many kinds of physical problems among the citizens. Many have lung problems, sores or heart problems. Some have stomach ulcers, and some have HIV or hepatitis. The nurse describes how she assists the citizens both in case of hospitalization and in their contact with general practitioners. Especially the contact with general practitioners can be a challenge as some doctors are not very sensitive to the needs of these citizens. Another issue concerns the coverage of costs for pharmaceuticals. In the Danish health system there is a partial user fee up to a certain level of expenditure for pharmaceuticals. For some of the citizens it can be difficult to pay for such expenditure. According to the health staff it could be a help if there was a budget to cover smaller expenditure for pharmaceuticals. Very recently the team has established a small medicine budget on a trial basis for a few of the citizens. The nurse describes how some of the ACT-citizens begin to have a need for more intensive nursing care, and especially how such needs may further develop in the future as the citizens get older. Hidden care needs may also appear as citizens leave the life on the streets behind, where such 26